Tuesday, April 28, 2009

Everyone wants Patient-Centered Primary Care ... but will they pay for it?

I am blogging today from a jam-packed meeting of health care leaders convened by the Patient-Centered Primary Care Collaborative (PCPCC), a coalition representing 400 of the most powerful stakeholders in American health care, physicians, employers, consumers, purchasers, and insurers alike. Today's meeting is to discuss opportunities and solutions to advance the patient-centered medical home model of health care delivery. Attendees are hearing from physicians who are implementing team-based care through the PCMH in the real world of practice, from the senior government official who is running the Medicare Medical Home demonstration, from experts in the role of health information technology in facilitating care coordination, from communication experts on the importance of presenting the benefits of the PCMH in way that resonates with consumers, and from yours truly, who will be discussing the political environment surrounding primary care and the PCMH. (Information on the presentations will be posted on the Patient-Centered Primary Care Collaborative web site - http://www.pcpcc.net/ - following today's meeting.)

The fact that so many people, representing the most influential constituencies in health care, are united to advance patient-centered primary care is good news indeed. Much has been accomplished.

On the political front, Senator Max Baucus (D-MT), chair of the Senate Finance Committee (SFC), is expected to release a paper later today that outlines his proposals to reform the health care delivery system, including advancing primary care (more about this tomorrow) and models to support prevention and care coordination like the Patient-Centered Medical Home. As I blogged about last week, Democrats and Republicans alike during last week's SFC roundtable, expressed a strong bipartisan commitment to reforming physician payments to support the value of primary care.

But as Robert Pear writes in yesterday's New York Times, translating the support on Capitol Hill for primary care into legislation will run right into the challenge of finding the money in a budget-neutral environment. The article quotes a spokesperson from a non-primary care physician organization who flatly rejected the idea that higher paid specialists might have to give up something to support their colleagues in primary care.

The hope of many of us is that Congress will decide that the value of primary care is such that it deserves a commitment of more federal funding, without running it through the usual budget-neutrality constraint that requires that more money for primary care come from other physicians or "providers." ACP has consistently advocated that Congress consider the demonstrated impact of primary care in achieving overall improvements in outcomes and reductions in health care spending, much of it related to reductions in preventable hospital admissions under Medicare Part A. The regular budget neutrality rules don't allow for savings in one part of Medicare (in this case, Part A) to be allocated to another (payments for primary care under Part B).

The challenge though is we may soon be facing tough choices. If Congress won't agree to put more "new" money on the table for primary care, the funding will have to come from someplace else. Yet I still have not heard anyone step up to the collection plate to commit the resources needed to adequately fund primary care so that it is competitive with other specialties, even though just about everyone says they agree on the need.

Unless payments for primary care are increased to the point where primary care is considered to be a viable and attractive career choice for young physicians and to sustain those already in practice, we can build all of the medical homes we want, but there will be no one home when the patient shows up for care.

Today's question: What advice would you give to Congress on finding the money to support higher payments for primary care, given budget-neutrality rules and resistance from other physicians and providers to redistributing money to primary care?


Jay Larson MD said...

Glenn Steele, jr., MD, PhD, President of Geisinger Health System had an interesting comment during last week's Senate Finance Committee round table. When asked if Geisinger had trouble recruting primary care physicians, he answered that they had no problem. They had no problem because the primary care physicians are reimbursed higher than other primary care physicians. It is the philosophy of Geisinger to support primary care. The specialists are willing to reduce their salaries to support primary care physicians also.

Unfortunately, the real world does not follow this paradigm.

PCP said...

Recently BCBS of Michigan rolled out a PCMH project with 2000 Doctors offices across the state.
What I found interesting was that they were prepared to pay................. Drumroll please "a whopping 10%" for the participating practices. Does anyone here realistically believe that with a 10% bump up in revenue, that we can invest in the needed technology, nursing staff, time etc to do this right?
Payers paying too little is a way to sabotage this effort. Generalist practices grasping at any straw for survival will jump in, however when the net investments needed are factored in, and the meager payment increases. The final result of this effort will be cost savings to the insurer which they will loathe to pass on to Patients.
Call me cynical, but perhaps someone can tell me how with a 10% bump in revenue they propose to make this work. I knew this the moment I heard about some pilot where the HMO was paying 3 bucks per member per month. Lets then wait until the NPs get their accreditation for these "medical homes" and see where the rates end up then. Why even our own ACP in their position paper said that should be one model of medical homes right.
Perhaps once we are finally extinguished from the primary care landscape, the NPs will have the cahunas to get more fairly reimbursed.
Those rates proposed are the sort of payment rates that even a fast food joint would turn down!
Is there any wonder that medical students are ignoring this as a window dressing?
They did get into medical school you know? I feel more and more like a Dinosaur every day.